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Referral and warning signs
When to refer
Refer ALL symptomatic patients (any cough, difficulty breathing, CNS symptoms) to Hospital (HC4/H) immediately for assessment, observation, and Chest X-ray. Refer asymptomatic patients if ingestion was significant, if vomiting occurred (increases aspiration risk), or if reliable observation at home is not possible. Urgent referral needed for respiratory distress, hypoxia, seizures, or altered consciousness.
Red flags
- Any respiratory symptom (cough, tachypnoea, dyspnoea, wheezing, grunting)
- Cyanosis
- Hypoxia (SpO2 <92%)
- Altered mental status (lethargy, confusion, coma)
- Seizures
- Vomiting after ingestion
Signs and symptoms
- Characteristic odor (paraffin, petrol, solvent) on breath or clothes.
- Oral/GI symptoms (if ingested): Burning sensation in mouth/throat, nausea, vomiting, abdominal pain, diarrhoea (occasionally bloody).
- Respiratory symptoms (KEY risk - Aspiration/Pneumonitis): Coughing, choking, gagging (often immediate if aspirated), dyspnoea (shortness of breath), tachypnoea (rapid breathing), wheezing, grunting, nasal flaring, chest pain, cyanosis (may be transient or persistent). Symptoms may be delayed for several hours.
- CNS symptoms (more common with volatile/aromatic hydrocarbons or large ingestions): Lethargy, drowsiness, dizziness, confusion, euphoria (solvent abuse), ataxia, headache, seizures, coma.
- Skin irritation or burns if prolonged contact.
Risk factors
- Accidental ingestion, especially by children, due to improper storage (e.g., storing in unlabeled beverage bottles).
- Occupational exposure (inhalation or skin contact with solvents, fuels).
- Recreational inhalation (solvent abuse, 'huffing').
- Siphoning petrol by mouth.
Diagnosis
Clinical assessment
Based on history of exposure (ingestion, inhalation, skin contact) to a hydrocarbon product. Characteristic odor. Clinical signs, especially respiratory symptoms (cough, tachypnoea, dyspnoea) are highly suggestive of aspiration. Assess neurological status.
Investigations
- Chest X-ray (CXR): Essential for diagnosis of chemical pneumonitis. Findings (basilar infiltrates, consolidation) may be delayed 4-12 hours after aspiration, so initial CXR can be normal. Repeat CXR if symptoms develop/persist.
- Pulse Oximetry (SpO2): Monitor for hypoxia.
- Arterial Blood Gas (ABG): Assess oxygenation and ventilation in patients with significant respiratory distress.
- Observe closely for development of respiratory symptoms if initially asymptomatic.
- Consider ECG if significant exposure or arrhythmia suspected.
Diagnostic criteria
Clinical presentation following known or suspected hydrocarbon exposure, especially with respiratory symptoms. CXR findings confirming pneumonitis support the diagnosis.
Management
Non-pharmacological management
- Stabilization: ABCDE approach.
- Decontamination: Remove contaminated clothing immediately. Wash affected skin with soap and water. Irrigate eyes if exposed.
- GI Decontamination: DO NOT INDUCE VOMITING. DO NOT PERFORM GASTRIC LAVAGE. These procedures increase the risk of aspiration, which is the main danger.
- Airway & Breathing: Ensure patent airway. Administer supplemental oxygen guided by SpO2 to maintain saturation >90-92%. Monitor respiratory status closely (rate, effort, breath sounds). Provide respiratory support (CPAP, intubation/mechanical ventilation) if severe respiratory distress, hypoxia, or ARDS develops (Hospital level).
- Supportive Care: Manage symptoms. IV fluids if dehydrated from vomiting/poor intake.
Pharmacological treatment
- Activated Charcoal: NOT indicated or effective for hydrocarbon poisoning.
- Antibiotics: NOT routinely indicated. Only use if evidence of secondary bacterial pneumonia develops (e.g., persistent fever, purulent sputum, worsening CXR infiltrates after initial stabilization). Prophylactic antibiotics are not beneficial.
- Bronchodilators (e.g., Nebulized Salbutamol): May be tried if wheezing is present, but efficacy variable.
- Corticosteroids: Generally NOT recommended; lack proven benefit and may increase risk of secondary infection.
- Seizures: Treat with Benzodiazepines (e.g., Diazepam, Lorazepam) IV.
Monitoring
Closely monitor respiratory status (RR, WOB, SpO2, auscultation) for at least 6-8 hours post-exposure, even if initially asymptomatic, as pneumonitis can be delayed. Monitor neurological status (GCS, seizures). Monitor temperature (fever). Repeat CXR as clinically indicated.
Complications
- Chemical pneumonitis (aspiration pneumonia)
- Acute Respiratory Distress Syndrome (ARDS)
- Respiratory failure
- Secondary bacterial pneumonia
- Pneumothorax, pneumatocele formation (rare)
- CNS toxicity (seizures, coma)
- Cardiac arrhythmias (especially with halogenated or aromatic hydrocarbons, or solvent abuse)
- Skin burns
- Death (usually from respiratory failure)
Prevention
- Store paraffin, petrol, solvents, and other hydrocarbons safely in original, clearly labeled containers.
- Keep these products out of reach of children, ideally in locked cupboards.
- NEVER store hydrocarbons in beverage bottles (e.g., soda or water bottles).
- Educate families and communities about the dangers of unsafe storage and ingestion/aspiration.
- Ensure adequate ventilation when using solvents or fuels indoors.
- Avoid siphoning petrol by mouth.
Patient education
- Explain the danger of aspiration and why vomiting must NOT be induced.
- Emphasize the critical importance of safe storage in original, labeled containers, away from children.
- Explain the need for observation even if initially well, as lung problems can be delayed.
- Discuss preventing future exposures.
Uganda-specific notes
Paraffin (kerosene) poisoning is particularly common in children due to its widespread use for lighting and cooking and frequent unsafe storage in beverage bottles. The absolute contraindication to inducing emesis or performing gastric lavage must be stressed. Management is supportive, focusing on respiratory care. Access to advanced respiratory support (ventilation) may be limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Section 1.3.3